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10
Consistency of Recommendations for Meal Requirements and Implementation Strategies with the Committee’s Criteria

The committee evaluated its recommendations for Meal Requirements for the Child and Adult Care Food Program (CACFP) and for the implementation of revised Meal Requirements using the criteria it established at the beginning of the study (see Chapter 6, Box 6-1). This chapter presents the committee’s assessment of the consistency of these recommendations with the criteria.

OVERVIEW

The committee’s criteria take into account the committee’s task (stated in Chapter 1), an array of background information on the need for revisions to CACFP meal patterns, topics relevant to revising the current standards, and the critical areas for consideration provided to the committee by the U.S. Department of Agriculture (USDA) (see Appendix D). In developing recommendations for revised Meal Requirements and their implementation, the committee recognized that it is impossible to fully meet each of the criteria. Instead, it strived to find the best balance—Meal Requirements that would lead to appealing meals of high nutritional quality and that would be practical in a variety of settings and moderate in cost.

RECOMMENDATIONS FOR MEAL REQUIREMENTS ARE CONSISTENT WITH THE CRITERIA

The first three recommendations to USDA are for revisions to the current CACFP Meal Requirements. The primary goal of the recommended



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10 Consistency of Recommendations for Meal Requirements and Implementation Strategies with the Committee’s Criteria The committee evaluated its recommendations for Meal Requirements for the Child and Adult Care Food Program (CACFP) and for the imple- mentation of revised Meal Requirements using the criteria it established at the beginning of the study (see Chapter 6, Box 6-1). This chapter presents the committee’s assessment of the consistency of these recommendations with the criteria. OVERVIEW The committee’s criteria take into account the committee’s task (stated in Chapter 1), an array of background information on the need for revisions to CACFP meal patterns, topics relevant to revising the current standards, and the critical areas for consideration provided to the committee by the U.S. Department of Agriculture (USDA) (see Appendix D). In developing recommendations for revised Meal Requirements and their implementation, the committee recognized that it is impossible to fully meet each of the cri- teria. Instead, it strived to find the best balance—Meal Requirements that would lead to appealing meals of high nutritional quality and that would be practical in a variety of settings and moderate in cost. RECOMMENDATIONS FOR MEAL REQUIREMENTS ARE CONSISTENT WITH THE CRITERIA The first three recommendations to USDA are for revisions to the cur- rent CACFP Meal Requirements. The primary goal of the recommended 169

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170 CHILD AND ADULT CARE FOOD PROGRAM Meal Requirements is to contribute to more healthful food and nutrient intakes by CACFP participants, especially in view of the high prevalence of obesity in the United States. As defined by the committee, the recommended Meal Requirements encompass both new meal patterns and new food specifications. The meal patterns are food-based targets that will promote intakes of healthy foods from five food groups: fruits, vegetables, low-fat dairy products, whole grains, and lean meats or meat alternates. The food specifications provide guidance on choices within these food groups that will lead to meals that have appropriate calorie levels and reduced amounts of solid fat, added sugars, and sodium. Although the impact of changes in the Meal Requirements on the daily food and nutrient intakes of CACFP participants cannot be predicted accurately, the recommended changes to the current Meal Requirements will likely improve the nutritional quality of the foods that are made available through the program. This, in turn, may have an indirect beneficial effect on food choices made outside the program, thus improving the overall nutritional status of participants. Consistency of the Meal Requirement Recommendations with Criterion One First Meal Requirement Recommendation The first of the committee’s recommendations addresses Meal Require- ments for infants and young children: USDA should adopt the recommended Meal Requirements for healthy infants up to 1 year of age. This recommendation brings infant feeding recommendations into align- ment with guidance from the American Academy of Pediatrics (AAP) and the Dietary Reference Intakes (DRIs), consistent with Criterion 1a. Criterion 1: The Meal Requirements will be consistent with current dietary guidance and nutrition recommendations to promote health with the ultimate goal of improving participants’ diets by reducing the preva- lence of inadequate and excessive intakes of food, nutrients, and calories. a. For infants and children younger than 2 years of age, the Meal Requirements will contribute to an overall diet that is consistent with established dietary recommendations for this age group and encourage and support breastfeeding for infants. b. For participants ages 2 years and older, the Meal Requirements will be exemplified by the Dietary Guidelines for Americans and the Dietary Reference Intakes.

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171 CONSISTENCY OF RECOMMENDATIONS WITH CRITERIA Key elements of the Meal Requirements appear below. (The meal pat- terns for this age group are presented in Chapter 7, Table 7-1.) • Infants from birth to 6 months will be fed breast milk or formula exclusively. • Infants ages 6–11 months will be fed breast milk or formula and appropriate solid foods. • For infants ages 6–11 months, developmental readiness is to be considered in offering complementary foods. • Infants from birth to 1 year will not be fed water or fruit juice. The Meal Requirements for young children are also consistent with the DRIs. Meat and suitable meat alternates are emphasized for infants ages 6–11 months of age, to address concerns about iron and zinc intakes. Although the committee was unable to develop strong incentives for breastfeeding through a mechanism related to the Meal Requirements, it encourages the development of such incentives. In addition, the recom- mendation to delay the introduction of solid foods until the infant is 6 months old is intended to encourage a longer period of full breastfeeding for breastfed infants. Second Meal Requirement Recommendation The second recommendation addresses variety and the quality of the foods served: For all children ages 1 year and older and for adults, USDA should adopt Meal Requirements that increase the variety of fruits and veg- etables, increase the proportion of whole grains, and decrease the content of solid fats, added sugars, trans fats, and sodium (Tables 7-2 through 7-8). This recommendation aligns adult and child feeding recommendations with the Dietary Guidelines for Americans and the DRIs, consistent with Crite- rion 1b, and recognizes that variety and diet quality are also important for younger children. Alignment with guidance for 1-year-old children The Meal Requirements for children 1 year of age were determined using three resources: AAP recommendations, MyPyramid food group recommendations for young children, and calorie and nutrient targets for children of this age. Although MyPyramid was not designed for children under 2 years of age, it was deemed to be an appropriate guide for setting meal patterns for 1-year-old children, with minor adjustments such as the use of whole milk rather than

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172 CHILD AND ADULT CARE FOOD PROGRAM BOX 10-1 Recommended Meal Requirements Improve Alignment with Dietary Guidelines • Better control of calories • More fruits and vegetables • A greater variety of vegetables • More whole grain-rich foods, fewer refined grain foods • Milk choices limited to nonfat and low-fat; no flavored milk for young children • Increased emphasis on limiting foods high in solid fats and added sugars • Minimized content of trans fat • Stronger emphasis on gradual reduction of sodium low-fat or nonfat milk. Thus, the amounts of food in the meal patterns provide young children who participate in CACFP with appropriate pro- portions of their daily nutrient needs, and Table 7-8 in Chapter 7 addresses appropriate food choices. Further information on the recommended Meal Requirements for 1-year-old children may be found in Chapter 7. Alignment with the Dietary Guidelines The committee reviewed the rec- ommended meal patterns for all age groups ages 2 years and older (Chapter 7, Tables 7-2 through 7-4), the food specifications (Chapter 7, Table 7-8), and the sample menus (Appendix K) to verify their correspondence with the Dietary Guidelines. It also determined the difference in the amounts of food in the current meal pattern with amounts in the recommended patterns (Chapter 8, Table 8-1). The recommended Meal Requirements clearly improve the alignment of CACFP meal patterns with the Dietary Guidelines (HHS/USDA, 2005). The amounts of fruits and vegetables are substantially higher in the new meal patterns for all these age groups, as is the proportion of whole grain-rich foods. In addition, milk products are the types encouraged in the Dietary Guidelines. The committee’s review of the sample menus (Appendix K), which gave special attention to the inclusion of a variety of fruits and vegetables, whole grain-rich products, and nonfat or low-fat milk products, found that these menus are also consistent with the Dietary Guidelines. Box 10-1 highlights key ways in which the recom- mended Meal Requirements align with the Dietary Guidelines. Examples of food specifications that show alignment with the Dietary Guidelines include the following: Low-fat milk products: Milk and yogurt will be nonfat or 1 percent • fat; the use of low-fat cheese is encouraged.

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173 CONSISTENCY OF RECOMMENDATIONS WITH CRITERIA Increasing the proportion of whole grains: At least half of grain • products must be whole grain-rich, and a higher proportion is encouraged. Decreasing the intakes of saturated fat and added sugars: Specifi- • cations limit milk fat and flavored milk; the only allowable form of juice is 100 percent juice with no added sugars; cereals are to contain less than 6 grams of sugar per ounce; and the frequency of use of high-fat meats and of grain foods high in solid fats and added sugars is limited. As an example of how well the recommended meal patterns conform to the MyPyramid patterns (and thus to Dietary Guidelines), Table 10-1 shows a comparison of the recommended meal pattern to the MyPyramid pattern for preschool children ages 2–4 years, the largest age group that is currently served meals (rather than just snacks) by CACFP; similar tables for all age groups are shown in Appendix Tables J-4 through J-7. For chil- dren ages 2–4 years, the recommended meal pattern contains more fruit than the MyPyramid pattern and a smaller amount of vegetables. Although vegetables are not required at breakfast, they are allowed as a substitute for fruit, and it is likely that actual weekly menus will contain some vegetables. The amounts of grains, milk, and lean meat or meat alternates in the recom- mended pattern are very similar to those in the MyPyramid pattern. Alignment with Dietary Reference Intakes To examine the alignment of the recommended Meal Requirements with the DRIs, the committee ana- lyzed the sample breakfast and lunch menus for each age group using the Meals Menu Analysis program (see Appendix K in IOM, 2010, for a de- scription of the program). The data are shown for children 2–4 years of age in Table 10-2, which compares the nutrients in the meal patterns with the daily nutrient targets by meal averaged over a 5-day week. Similar tables for all other age groups are shown in Appendix J, Tables J-8 through J-11. Notably, the sample menus meet or nearly meet the nutrient targets in almost all cases. Although calories appear to be somewhat low for all meals, additional calories will be provided by healthy fats and other fats and sugars that are permitted by the food specifications (e.g., the fat in 1 percent fat milk, and sugars in cereals and yogurt). Based on analyses across all age groups, it appears prudent to make gradual changes to serve more foods that are rich in vitamin E and linoleic and a-linolenic acid (such as vegetable oils; nuts, seeds, and nut butters; and whole grains). The foods that are offered for this purpose need to be afford- able, well accepted, and tolerated by CACFP participants (considering their age and physical abilities), and they need to fit within the calorie allowance. Although peanut butter is an example of a good source of vitamin E and the

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TABLE 10-1 Comparison of MyPyramid Food Group Targets with MyPyramid Food Groups in Recommended 174 Meal Patterns for Children 2–4 Years of Age Weekly (5-Day) Allowance per Meal 1,300-Calorie MyPyramid Patterna for 2–4-Year-Oldsb Breakfast Lunch/Supper Snack 1,300-kcal 5-Day 1,300-kcal Daily 5-Day Weekd Weekly Food Groupc MyPyramid Amts MyPyramid Amts 20%e Patternf 26% Patternf 14% Patternf Totalg Fruit (c) 1.25 6.25 1.25 2.5 1.63 2.5 0.88 1 9.5 Vegetables (c) 1.5 7.5 0 0 2.0 2.5 1.1 0.5 6 Dark green (c/wk) 1.5 1.1 0 0 0.28 0.5 0.15 0 1 Orange (c/wk) 1 0.7 0 0 0.19 0.5 0.10 0.25 1.5 Dry beans (c/wk) 1 0.7 0 0 0.19 0.25 0.10 0 0.5 Starchy (c/wk) 2.5 1.8 0 0 0.46 0.5 0.25 0 1 Other (c/wk) 4.5 3.2 0 0 0.84 0.75 0.45 0.25h 2 Grains (oz eq) 4.5 22.5 4.5 7 5.9 5 3.2 2 21 Meat and beans (oz eq) 3.5 17.5 3.5 3 4.6 5 2.5 2 17 Milk (c) 2 10 2.0 2.5 2.6 2.5 1.4 1 9.5 NOTES: Amts 5 amounts; c 5 cup; kcal 5 calories; oz eq 5 ounce equivalent; wk 5 week. The comparison of MyPyramid food group targets with the MyPyramid food groups in the recommended meal patterns for children ages 1 year, 5–13 years, 14–18 years, and adults are located in Appendix J, Tables J-4 through J-7. For consistency within the table, decimals, instead of fractions, are used in tables comparing MyPyramid pattern amounts and recommended CACFP 5-day meal patterns. a1,300-calorie pattern based on an average of the 1,200- and 1,400-calorie patterns. bOil 5 17 grams/day; discretionary calories 5 171 kcal/day. cSee Appendix Table H-1 for a list of foods in the MyPyramid food groups and subgroups. dDaily MyPyramid amounts multiplied by 5 to represent goals for a 5-day week. eProportional amount in each meal, based on the percent of calories in the meal; vegetables are not required at breakfast. fAmounts in the meal pattern for each meal. gTotal MyPyramid amounts are calculated as follows: breakfast 1 lunch 1 supper 1 two snacks. hThe other vegetables served at snack are to be non-starchy vegetables only. SOURCE: MyPyramid patterns from Britten et al., 2006.

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175 CONSISTENCY OF RECOMMENDATIONS WITH CRITERIA TABLE 10-2 Comparison of Nutrients in Recommended Meal Patterns with Nutrient Targets Averaged Over a 5-Day Week for CACFP for Children 2–4 Years of Age Breakfast Lunch/Supper Snack Nutr. Nutr. in % Nutr. Nutr. in % Nutr. Nutr. in % Targets Meals Diff. Targets Meals Diff. Targets Meals Diff. Calories (kcal) 260 283 9 338 331 –2 182 142 –22 % Calories from fat 25–35 22 NA 25–35 26 NA 25–35 32 NA % Calories from sat. fat , 10 8 NA , 10 9 NA , 10 11 NA Protein (g/d) 8.0 12 54 10 16 56 5.6 5.6 0 Vitamin A (μg RAE/d) 92 171 85 120 276 130 65 113 75 Vitamin C (mg/d) 15 18 21 20 28 41 11 7.5 –29 Vitamin E (mg αT/d) 1.4 0.40 –72 1.8 1.4 –24 1.0 0.49 –51 Thiamin (mg/d) 0.18 0.46 155 0.23 0.30 28 0.13 0.11 –13 Riboflavin (mg/d) 0.24 0.60 147 0.32 0.46 46 0.17 0.20 18 Niacin (mg/d) 2.4 4.7 101 3.1 4.0 31 1.6 1.3 –19 Vitamin B6 (mg/d) 0.20 0.53 171 0.25 0.39 54 0.14 0.13 -5 Folate (μg DFE/d) 63 183 189 82 99 20 44 42 –5 Vitamin B12 (μg/d) 0.56 1.6 186 0.72 1.1 45 0.39 0.44 13 Iron (mg/d) 1.7 4.6 172 2.2 2.5 12 1.2 1.0 –14 Magnesium (mg/d) 30 50 69 39 67 74 21 26 26 Zinc (mg/d) 1.3 2.7 119 1.6 2.3 42 0.88 0.89 2 Calcium (mg/d) 120 227 89 156 235 51 84 122 45 Phosphorus (mg/d) 167 261 56 217 304 40 117 129 11 Potassium (mg/d) 653 489 –25 849 656 –23 457 245 –46 Sodium (mg/d) , 327 411 26 , 425 656 54 , 229 228 0 Linoleic acid (g/d) 1.6 0.96 –40 2.1 1.7 –19 1.1 0.85 –24 α-linolenic acid (g/d) 0.15 0.07 –54 0.20 0.19 –5 0.11 0.06 –44 Fiber (g/d) 4.2 3.3 –22 5.5 5.4 –2 2.9 1.7 –43 NOTE: αT 5 α-tocopherol; CACFP 5 Child and Adult Care Food Program; d 5 day; DFE 5 dietary folate equivalent; diff 5 difference; g 5 grams; kcal 5 calories; μg 5 micrograms; mg 5 milligrams; mo 5 month; NA 5 not applicable; nutr 5 nutrient; sat. fat = saturated fat; y 5 year.

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176 CHILD AND ADULT CARE FOOD PROGRAM unsaturated fatty acids, it is a food that many CACFP providers omit from meals because of concerns about nut allergies. The three nutrients that merit special attention—vitamin E, folate, and iron for meals served to children ages 12 years and older—are the same nutrients that were identified in the report School Meals: Building Blocks for Healthy Children (IOM, 2010). Because no representative baseline menus were available, it was not possible to accurately determine changes in the nutrient content of menus based on the revised Meal Requirements. To obtain a rough estimate of the changes in nutrient content resulting from the modifications in require- ments, however, the committee conducted an analysis using the baseline and revised food group composites (see Chapter 8 and Appendix I). The analysis specified differences in food take-up rates based on differences between cur- rent and recommended meal patterns. This crude analysis for children 2–4 years of age (see Table 10-3) shows that calories were slightly higher or the same as in the current meal patterns, but saturated fat decreased and most other nutrients increased at all the meals. Similar tables for all other age groups are shown in Appendix J, Tables J-12 through J-15. Effects of nutrient intakes from CACFP meals on total daily nutrient in- takes The analyses of the menu patterns (Chapter 7) and the recom- mended meal patterns (revised composites) (Table 10-2) and the comparison of revised composites with baseline composites (Table 10-3) all show that meals planned according to the recommended Meal Requirements, if they are consumed, have the potential to improve total daily nutrient intakes. Consistency of the Meal Requirement Recommendations with Other Criteria Recommendations 1 and 2 Regarding Meal Patterns and Food Specifications Criterion 2 Both components of the recommended Meal Requirements—the meal patterns and the food specifications—contribute to meeting the goals specified in Criterion 2. Criterion 2: The Meal Requirements will provide the basis for menus that are practical to plan, prepare, and serve in different settings. The meal patterns allow choice from a wide range of foods, and the food specifications eliminate the need to count calories, saturated fat, or nu- trients. State agencies would have the option of making food specifications

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TABLE 10-3 Comparison of Nutrients at Baseline with Nutrients in Recommended Meal Patterns for Children 2–4 Years of Age Breakfast Lunch/Supper Snack Baseline Revised % Change Baseline Revised % Change Baseline Revised % Change Calories (kcal) 172 283 64 280 331 18 113 142 26 Fat (g) 4.7 7.0 50 12 9.6 –17 3.3 5.1 55 % Calories from Fat 24 22 –9 37 26 –30 26 32 23 Sat. fat (g) 2.4 2.5 4 4.8 3.2 –33 1.1 1.7 55 % Calories from sat. fat 13 8 –37 15 9 –43 9 11 23 Protein (g/d) 7.0 12 75 16 16 4 3.2 5.6 78 Vitamin A (µg RAE/d) 119 171 44 154 276 79 33 113 243 Vitamin C (mg/d) 14 18 34 11 28 162 9.8 7.5 –24 0.28 0.40 43 0.76 1.4 84 0.27 0.49 81 Vitamin E (mg αT/d) Thiamin (mg/d) 0.18 0.46 156 0.24 0.30 25 0.09 0.11 22 Riboflavin (mg/d) 0.41 0.60 46 0.45 0.46 2 0.13 0.20 54 Niacin (mg/d) 1.4 4.7 236 3.1 4.0 31 0.94 1.3 41 0.24 0.53 121 0.27 0.39 44 0.10 0.13 30 Vitamin B6 (mg/d) 55 183 230 60 99 65 30 42 40 Folate (μg DFE/d) 1.0 1.6 59 1.2 1.1 –15 0.21 0.44 110 Vitamin B12 (μg/d) Iron (mg/d) 1.3 4.6 262 1.6 2.5 56 0.75 1.0 36 Magnesium (mg/d) 32 50 57 45 67 49 17 26 58 Zinc (mg/d) 1.1 2.7 151 2.1 2.3 8 0.45 0.89 98 Calcium (mg/d) 219 227 3 250 235 –6 64 122 92 Phosphorus (mg/d) 200 261 31 287 304 6 72 129 79 Potassium (mg/d) 410 489 19 504 656 30 180 245 36 Sodium (mg/d) 166 411 147 493 656 33 129 228 76 Linoleic acid (g/d) 0.43 0.96 123 1.4 1.7 21 0.58 0.85 47 0.07 0.07 0 0.16 0.19 19 0.05 0.06 20 α-linolenic acid (g/d) Fiber (g/d) 1.7 3.3 98 2.4 5.4 122 1.1 1.7 53 NOTE: αT 5 α-tocopherol; CACFP 5 Child and Adult Care Food Program; d 5 day; DFE 5 dietary folate equivalent; g 5 grams; kcal 5 calories; μg 5 micrograms; 177 mg 5 milligrams; mo 5 month; sat. fat 5 saturated fat; y 5 year.

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178 CHILD AND ADULT CARE FOOD PROGRAM easier to use by identifying lists of foods that need to be limited because of their content of solid fats, added sugars, and/or sodium. Criterion 3 The meal patterns and food specifications that make up the Meal Requirements clearly provide the basis for incorporating nutritious foods and beverages, as specified in Criterion 3. Criterion 3: The Meal Requirements will provide the basis for menus that incorporate healthful foods and beverages and are appealing to diverse age ranges and cultural backgrounds. The choices within the five major food groups (meal components) allow for menus suitable for many different cultures. The sample menus in Chap- ter 7 and Appendix K follow the recommended Meal Requirements and are quite similar to menus that are used and well accepted in CACFP facilities in the southwestern United States. Nonetheless, the committee recognizes that a number of the recommended changes listed below will call for new measures (see Chapter 9) to increase the appeal of some of the foods: • Dark green and orange vegetables and legumes on the menu each week. Few children and adults eat the amounts of vegetables recom- mended in MyPyramid (National Health and Nutrition Examina- tion Survey [NHANES] 2003–2004; see Tables 4-1 and 5-1). Each vegetable subgroup includes many choices, however, and favorites from each group may be prepared in appealing ways. • More vegetables at lunch but starchy vegetables served less often. Data from NHANES 2003–2004 indicate that vegetable consump- tion by children and adults is very low, with the exception of potato consumption (see Tables 4-1 and 5-1). However, the com- mittee anticipates that parents and participants will ultimately appreciate the value of nutritionally improved CACFP meals and that, with repeated exposures, participants will learn to better ap- preciate the vegetable items offered (see the section “Implementing Key Elements for Clients Ages 1 Year and Older” in Chapter 9 for the basis of this expectation). • Milk choices limited to fat-free (plain or flavored) and plain low- fat (1 percent milk fat or less) for participants over 2 years of age. Currently, a majority of American school-age children consume milk with a fat content of 2 percent or more, or flavored milk with at least 1 percent milk fat (USDA/FNS, 2008). Gradual reduction in the fat content of the milk may promote acceptance of the lower fat milks.

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179 CONSISTENCY OF RECOMMENDATIONS WITH CRITERIA • More whole grain-rich food products, fewer refined grain products. Data from 2003–2004 (covered in Chapters 4 and 5) indicate that the consumption of whole grains by both children and adults is very low. This may be, in part, a function of the availability of suitable and appetizing whole grain foods. The committee antici- pates that the availability of appealing and palatable whole grain products will increase with time. • Nearly all entrées, cheese, and grain products are low in saturated fat. Modified recipes and training in food preparation can help make these foods more acceptable. Minimal levels of trans fat in foods. Although many processed • foods still contain trans fat, added trans fats are being reduced or eliminated from the food supply. Little effect on the acceptability of these foods is expected. Fewer desserts with meals. Anecdotal evidence and evidence from • Dillon and Lane (1989) indicate that desserts are very popular when served. They need to be limited, however, because they are a prominent source of solid fats, added sugars, and sodium and are typically low in nutrients and fiber. Less sodium in meals. High sodium intake is typical for U.S. children • and adults. Modified recipes and training in food preparation and presentation can help providers reduce sodium in meals while retain- ing their appeal, but providers will need to depend to a large extent on sodium reductions by the food industry. For providers who can shop in stores large enough to offer a reasonable selection of foods, training in label reading may be very helpful. The reduction of the sodium content of CACFP meals is expected to be gradual. The committee acknowledges the value of a gradual phase-in period to accustom participants to the changes in the menus and also to give the providers time to improve their skills for preparing and serving appealing meals according to the recommended Meal Requirements. The committee is optimistic that participants and providers will benefit from more health- ful meals served at CACFP homes and centers and that, with effective implementation of the recommended Meal Requirements by providers, participants will find the meals appealing. Criterion 4 The committee developed the Meal Requirements with provid- ers in mind, as specified by Criterion 4. Criterion 4: The Meal Requirements will facilitate the planning of menus that are compatible with the capabilities and resources for the variety of program providers.

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180 CHILD AND ADULT CARE FOOD PROGRAM The intent was to make the recommended Meal Requirements adapt- able to different provider venues: day care homes, centers, and other facili- ties such as Head Start. However, in the short term, program providers in all these venues are likely to face challenges in obtaining acceptable prod- ucts, especially whole grain-rich foods and foods that are reduced in solid fats, added sugars, and sodium. Changes in the types of food served, such as more fruits and vegetables, may increase preparation time and requirements for equipment and refrigeration. This is a particular concern for day care homes with small kitchens and limited resources (see Chapter 9). Criterion 5 Throughout the process of developing the Meal Requirements, the committee kept cost in mind, as specified in Criterion 5. Criterion 5: The Meal Requirements will allow the planning of menus that are sensitive to considerations of cost. Nonetheless, revisions to the current Meal Requirements to improve align- ment with Dietary Guidelines and the DRIs result in increased costs. In particular, as demonstrated in Chapter 8, increasing the amount of fruits, vegetables, and whole grain-rich foods in meals and snacks served by CACFP providers increases food costs. The expected increase will likely exceed the amount that can be absorbed by CACFP providers under current federal reimbursement levels. Meal Requirement Recommendation 3 Regarding Enhanced Snack Option The last of the recommendations for the Meal Requirements provides the option of an enhanced snack for adults and children 5 years of age and older: USDA should give CACFP providers the option of serving one en- hanced snack in the afternoon in place of a smaller snack in both the morning and the afternoon. This recommendation is particularly supportive of Criterion 2, to pro- vide menus that incorporate healthful foods and beverages and are appeal- ing to diverse age ranges and cultural backgrounds. The committee believes that an enhanced snack will be particularly appealing to older adults and to school-age children who participate in afterschool CACFP programs. The larger snack will also have the potential to add more healthful foods and beverages to the daily diet for those who may not consume a nutritious dinner and those who would otherwise consume less healthful snack items.

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181 CONSISTENCY OF RECOMMENDATIONS WITH CRITERIA Because an enhanced snack provides more food items, it can be better tai- lored to cultural and other types of food preferences. RECOMMENDATIONS FOR IMPLEMENTATION STRATEGIES ARE CONSISTENT WITH THE CRITERIA First Implementation Recommendation The first of the recommendations for implementation strategies ad- dresses the need to help CACFP providers with the transition to the new Meal Requirements: USDA, working together with state agencies and health and professional organizations, should provide extensive technical assistance to CACFP providers to implement the recommended Meal Requirements. This recommendation is particularly relevant to Criterion 3, which states that menus should be practical to plan, purchase, prepare, and serve in different settings. The committee recognizes that the recommended meal patterns are more complex than the current ones, especially because of the weekly requirements for vegetable subgroups and the requirement that at least half of the grains be whole grain-rich. In addition, limits on the fre- quency of use of foods high in solid fats and added sugars will call for care- ful attention to menu planning. Under the current requirements, the focus is simply providing minimum amounts of foods from four food components, and there is considerable leeway for offering extra menu items (such as condiments) and foods high in solid fats and added sugars. Technical assis- tance in the form of well-targeted training and new resource materials will be needed to equip CACFP providers to meet the menu planning challenges posed by the recommended Meal Requirements (see Chapter 9). This implementation recommendation also supports Criterion 4, which focuses on providers’ capabilities and resources. Providers in all venues will need training and other types of support to plan menus that meet the rec- ommended Meal Requirements and that are realistic for their situation. Second Implementation Recommendation The second recommendation related to implementation strategies con- siders how providers and sponsors will be monitored and reimbursed: USDA should work strategically with the CACFP administering state agencies, CACFP associations, and other stakeholders to reevaluate and streamline the system for monitoring and reimbursing CACFP meals and snacks.

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182 CHILD AND ADULT CARE FOOD PROGRAM This recommendation is particularly relevant to Criterion 4, which addresses the capabilities and resources of program providers, and also to Criterion 5, which addresses cost. As discussed in Chapter 9, providers will need an easily followed revised reporting method to demonstrate that the meals they serve are eligible for reimbursement through CACFP. Further- more, an efficient revised system for both monitoring and reimbursement will help control administrative costs. SUMMARY It is clear that the recommended Meal Requirements will result in menus that are more closely aligned with the Dietary Guidelines and the DRIs than are menus planned using the current meal requirements. In particular, the recommended Meal Requirements will provide more fruits and vegetables, a wider variety of vegetables, and a higher proportion of whole grain-rich foods while decreasing the offering of foods that are high in solid fats, added sugars, and sodium. However, these improvements in nutritional quality can be achieved only at somewhat higher cost and only if measures are taken to gain the support of providers, to develop some new skills, and to develop a streamlined system for monitoring and reimbursing CACFP meals and snacks. The committee anticipates that the recommended Meal Requirements are attainable with appropriate support for their implementation. REFERENCES Britten, P., K. Marcoe, S. Yamini, and C. Davis. 2006. Development of food intake patterns for the MyPyramid Food Guidance System. Journal of Nutrition Education and Behavior 38(6 Suppl):S92. Dillon, M. S., and H. W. Lane. 1989. Evaluation of the offer vs. serve option within self-serve, choice menu lunch program at the elementary school level. Journal of the American Dietetic Association 89(12):1780–1785. HHS/USDA (U.S. Department of Health and Human Services/U.S. Department of Agriculture). 2005. Dietary Guidelines for Americans, 6th ed. Washington, DC: U.S. Government Printing Office. http://www.health.gov/DietaryGuidelines/dga2005/document/ (accessed July 23, 2008). IOM (Institute of Medicine). 2010. School Meals: Building Blocks for Healthy Children. Washington, DC: The National Academies Press. USDA/FNS (U.S. Department of Agriculture/Food and Nutrition Service). 2008. Diet Quality of American School-Age Children by School Lunch Participation Status: Data from the National Health and Nutrition Examination Survey, 1999–2004. Alexandria, VA: USDA/ FNS. http://www.fns.usda.gov/OANE/menu/published/CNP/FILES/NHANES-NSLP.pdf (accessed August 20, 2008).